Clinical manifestations and diagnosis of acute diverticulitis in adults
- John H Pemberton, MD
John H Pemberton, MD
- Professor of Surgery
- Mayo Clinic and Mayo Medical School
Approximately 4 percent of patients with diverticulosis develop acute diverticulitis (algorithm 1) [1,2]. Diverticulitis results from a microscopic or macroscopic perforation of a diverticulum due to diverticular inflammation and focal necrosis.
This topic will review the clinical manifestations and diagnosis of acute diverticulitis. The epidemiology of diverticulosis, diverticular disease, and diverticular bleeding and the management of acute diverticulitis and diverticular bleeding are discussed in detail, separately. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis" and "Acute colonic diverticulitis: Medical management" and "Acute diverticulitis complicated by fistula formation" and "Colonic diverticular bleeding".)
●A diverticulum is a sac-like protrusion of the colonic wall.
●Diverticulosis merely describes the presence of diverticula.
●Acute diverticulitis is defined as inflammation, generally considered to be due to microperforation of a diverticulum.
- Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969; 4:639.
- Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol 2013; 11:1609.
- Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg 2009; 249:210.
- Nguyen GC, Sam J, Anand N. Epidemiological trends and geographic variation in hospital admissions for diverticulitis in the United States. World J Gastroenterol 2011; 17:1600.
- Sugihara K, Muto T, Morioka Y, et al. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984; 27:531.
- Markham NI, Li AK. Diverticulitis of the right colon--experience from Hong Kong. Gut 1992; 33:547.
- Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med 2007; 357:2057.
- Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984; 200:466.
- Textbook of Gastroenterology, Yamada T, Alpers DH, Kaplowitz N, et al (Eds), Lippincott Williams & Wilkins, Philadelphia, PA 2003.
- Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975; 4:53.
- Konvolinka CW. Acute diverticulitis under age forty. Am J Surg 1994; 167:562.
- Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of complicated diverticular disease. Am J Surg 2003; 186:696.
- Ambrosetti P, Chautems R, Soravia C, et al. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005; 48:787.
- Woods RJ, Lavery IC, Fazio VW, et al. Internal fistulas in diverticular disease. Dis Colon Rectum 1988; 31:591.
- Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985; 28:71.
- Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis 1994; 9:158.
- Salem L, Flum DR. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47:1953.
- Constantinides VA, Tekkis PP, Athanasiou T, et al. Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 2006; 49:966.
- Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases. Surgery 1994; 115:546.
- Birnbaum BA, Balthazar EJ. CT of appendicitis and diverticulitis. Radiol Clin North Am 1994; 32:885.
- Hulnick DH, Megibow AJ, Balthazar EJ, et al. Computed tomography in the evaluation of diverticulitis. Radiology 1984; 152:491.
- Goh V, Halligan S, Taylor SA, et al. Differentiation between diverticulitis and colorectal cancer: quantitative CT perfusion measurements versus morphologic criteria--initial experience. Radiology 2007; 242:456.
- Laméris W, van Randen A, Bipat S, et al. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol 2008; 18:2498.
- Snyder MJ. Imaging of colonic diverticular disease. Clin Colon Rectal Surg 2004; 17:155.
- Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2008; 51:1810.
- Heverhagen JT, Zielke A, Ishaque N, et al. Acute colonic diverticulitis: visualization in magnetic resonance imaging. Magn Reson Imaging 2001; 19:1275.
- McKee RF, Deignan RW, Krukowski ZH. Radiological investigation in acute diverticulitis. Br J Surg 1993; 80:560.
- Stollman NH, Raskin JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999; 94:3110.
- Trenkner SW, Thompson WM. Since the advent of CT scanning, what role does the contrast enema examination play in the diagnosis of acute diverticulitis? AJR Am J Roentgenol 1994; 162:1493.
- Padidar AM, Jeffrey RB Jr, Mindelzun RE, Dolph JF. Differentiating sigmoid diverticulitis from carcinoma on CT scans: mesenteric inflammation suggests diverticulitis. AJR Am J Roentgenol 1994; 163:81.
- Chintapalli KN, Chopra S, Ghiatas AA, et al. Diverticulitis versus colon cancer: differentiation with helical CT findings. Radiology 1999; 210:429.
- Johnson CD, Baker ME, Rice RP, et al. Diagnosis of acute colonic diverticulitis: comparison of barium enema and CT. AJR Am J Roentgenol 1987; 148:541.
- Balthazar EJ, Megibow A, Schinella RA, Gordon R. Limitations in the CT diagnosis of acute diverticulitis: comparison of CT, contrast enema, and pathologic findings in 16 patients. AJR Am J Roentgenol 1990; 154:281.
- Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014; 259:263.
- Bharucha AE, Parthasarathy G, Ditah I, et al. Temporal Trends in the Incidence and Natural History of Diverticulitis: A Population-Based Study. Am J Gastroenterol 2015; 110:1589.
- Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute Technical Review on the Management of Acute Diverticulitis. Gastroenterology 2015; 149:1950.
- Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011; 54:283.
- Binda GA, Arezzo A, Serventi A, et al. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 2012; 99:276.
- Mäkelä JT, Kiviniemi HO, Laitinen ST. Spectrum of disease and outcome among patients with acute diverticulitis. Dig Surg 2010; 27:190.
- Cohen E, Fuller G, Bolus R, et al. Increased risk for irritable bowel syndrome after acute diverticulitis. Clin Gastroenterol Hepatol 2013; 11:1614.
- Horgan AF, McConnell EJ, Wolff BG, et al. Atypical diverticular disease: surgical results. Dis Colon Rectum 2001; 44:1315.
- Lamps LW, Knapple WL. Diverticular disease-associated segmental colitis. Clin Gastroenterol Hepatol 2007; 5:27.
- Strate LL, Modi R, Cohen E, Spiegel BM. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol 2012; 107:1486.
- Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49:939.
- Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994; 76:117.
- Constantinides VA, Tekkis PP, Senapati A, Association of Coloproctology of Great Britain Ireland. Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 2006; 93:1503.
- CLINICAL FEATURES
- Clinical manifestations
- - Acute complications
- - Abscess
- - Obstruction
- - Perforation
- Laboratory findings
- - Computed tomography scan
- - Abdominal ultrasound
- - Magnetic resonance imaging
- - Abdominal and chest radiographs
- Diagnostic evaluation
- DIFFERENTIAL DIAGNOSIS
- EXCLUSION OF AN UNDERLYING MALIGNANCY
- NATURAL HISTORY
- Disease course
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS